Stepped preventive care after trauma

1. Introduction

Version followed: Stepped Preventive Care (SPC) as specified by Kassam-Adams, García-España, Marsac, Kohser, Baxt, Nance and Winston (2011, Journal of Traumatic Stress 24(3):252–259), developed at the Children's Hospital of Philadelphia (CHOP) for hospitalised injured children aged 8–17 and their parents. Its adult parent model, Zatzick's stepped collaborative care for injured trauma-centre patients, is described from the TSOS6 trial protocol (NCT02655354, 2018 version) where the paediatric paper is silent. Universal bedside care follows the NCTSN paediatric medical traumatic stress toolkit (D-E-F protocol); parent materials follow CHOP's After the Injury resources.

Stepped Preventive Care is a service-delivery model for secondary prevention, not a single therapy. It is a sequence of screening, brief low-intensity contacts and decision points, built into acute medical care, that sends each injured child and family to the lowest level of help that meets their needs. More intensive mental-health care is held back for the minority who do not recover. [source: Kassam-Adams et al. 2011]

Core idea of change: most children recover from injury-related traumatic stress with time and ordinary support. Prevention therefore works by (1) finding the higher-risk minority early, (2) strengthening natural recovery processes, chiefly parents' emotional support, information, routine and access to medical care, (3) watching symptoms over time, and (4) stepping up to assessment and trauma-focused treatment when symptoms are severe or persistent. The authors describe matching "individual needs to appropriate level of intervention", adapting Zatzick et al.'s (2004) adult stepped collaborative care with a central role for parents. [source: Kassam-Adams et al. 2011; After the Injury: Helping My Child Cope]

Scope note: in the 2011 pilot RCT, SPC did not reduce PTSD symptoms more than usual care. The authors concluded that the low-intensity steps may not be "potent enough" on their own for higher-risk children and recommended a later decision point (about 6 weeks) for stepping up. This guide includes those revisions and marks them. [source: Kassam-Adams et al. 2011]

2. Framework

Format and staff. The model was delivered in a paediatric trauma centre by one nurse and two social workers. They had paediatric experience but no specialised traumatic-stress training, received brief training, and were supervised by a doctoral-level psychologist. A second psychologist was available for assessment and trauma-focused therapy, and child psychiatry for medication assessment. Training hours and supervision frequency were not reported. [source: Kassam-Adams et al. 2011] In the adult model, care managers (RN, MSW or PhD level) receive a one-day on-site workshop, weekly individual supervision and 1–4 team calls a month, and log their work in a web-based decision-support tool. [source: TSOS6 protocol]

Step 0. Universal trauma-informed medical care (all injured children). Bedside staff use the D-E-F approach: attend to Distress (information, choices, listening, clarifying misconceptions, asking about fears, realistic hope), Emotional support (parent presence, empowering parents, normal activities) and Family (family distress, coping resources and stressors; screen; involve psychosocial staff for higher-risk families). [source: NCTSN Pediatric Medical Traumatic Stress Toolkit]

Screening (targeted step). Within 2 weeks of injury and during admission (mean 2.3 days), three brief measures are given and scored immediately: the Child PTSD Symptom Scale (positive at 15 or more), the CES-D (positive at 24 or more for youth) and the STEPP risk screen (positive at 4 or more of 8 items in the 2011 paper). A positive result on any one measure counts as screen-positive. Exclusions in the trial were moderate to severe head injury (GCS 12 or below), medical instability, intentional injury, and no telephone or English. [source: Kassam-Adams et al. 2011]

Step 1. Session 1, in hospital (indicated step). This took place a mean of 3.0 days after injury and lasted 10–75 minutes (mean 29). It covers the child's and parent's top concern; a semistructured review of current distress, support systems and medical questions; and the psychoeducation binder. Decision rules are applied at the end of the session. [source: Kassam-Adams et al. 2011]

Step 2. Session 2, follow-up (monitoring step). This takes place about 2 weeks after discharge, usually by telephone, and lasted 10–50 minutes (mean 18). It reviews progress, distress and symptoms, support and medical follow-up, and the decision rules are applied again. [source: Kassam-Adams et al. 2011]

Step-up options (applied at each session by decision rules): (a) additional family contact; (b) contact with medical providers for care coordination, adherence to medical follow-up, or to make them aware of the child's emotional recovery; (c) a brief parent–child intervention to build a shared view of the child's needs and help parents support adaptive coping; (d) evaluation by a psychologist or psychiatrist; (e) trauma-focused CBT for severe or persistent PTSD symptoms. [source: Kassam-Adams et al. 2011]

Dose in practice. Of the children who received Session 1, 85% were rated low intensity, 12% moderate and 2% high. Three children needed formal mental-health assessment or treatment. On average, contact beyond the two sessions added about 11 minutes per case. [source: Kassam-Adams et al. 2011]

Criteria for moving between steps. The paper names decision rules but publishes no numeric thresholds beyond "severe or persistent" PTSD symptoms for option (e). [uncertain] The working criteria below are my own and are consistent with the sources. [synthesis]

Screen-negative children: Step 0 plus parent written materials. The parent is told the warning signs, and further help is offered if reactions last more than a few weeks. [source for the warning signs: After the Injury: Helping My Child Cope]
To option (a): Session 2 could not be completed, a family raises new concerns, or there are practical stressors (housing, finances, school) that need linking to resources.
To option (b): missed medical appointments, unmanaged pain, unanswered medical questions, or symptoms the medical team should know about.
To option (c): child and parent disagree about the child's distress, the parent is unsure how to help, or there is avoidance or worry the parent is unintentionally reinforcing.
To options (d) and (e): at about 4–6 weeks, PTSD or depression symptoms are still at or above the screening cut-offs with impaired functioning (school refusal, dropping activities), symptoms are getting worse, there is any suicidal ideation, or there is prior or current psychiatric history. Kassam-Adams et al. (2011) recommend re-assessing at about 6 weeks and using that as the decision point for the parent–child intervention or trauma-focused treatment.
The adult model gives one published trigger: a nurse is notified when the PTSD Checklist score is 35 or higher or the PHQ-9 suicide item is 1 or higher. [source: TSOS6 protocol]

Duration. In the paediatric model, active contact ran from admission to about 2 weeks after discharge, with a recommended reassessment at 6 weeks. In the adult model, care management continues for up to 6 months after injury, at about 2–4 hours of care-manager time per patient, and ends with a hand-off to primary care. [source: Kassam-Adams et al. 2011; TSOS6 protocol]

3. Guiding principles

Match intensity to need. Give each family the least intensive help that works, and keep specialist treatment for those who need it. [source: Kassam-Adams et al. 2011]
Watchful waiting, not watchful neglect. Early guidelines call for monitoring plus screening rather than routine treatment. In practice, every screen-positive family gets a scheduled follow-up, not just an open invitation. [source: Kassam-Adams et al. 2011]
Normal reactions are expected. Confusion, upset, jumpiness and worry in the first days are normal, and most children need only a little extra time. In practice, normalise the reactions and avoid labelling early distress as disorder. [source: After the Injury: Helping My Child Cope]
Duration is the signal. Reactions that persist beyond a few weeks, or that get worse, call for more help. In practice, track symptoms across time points rather than deciding from a single snapshot. [source: After the Injury; Kassam-Adams ISRII 2009]
Parents are the main agents of recovery and the gatekeepers to care. In practice, work through the parent, and equip them to read the child's reactions, help, and seek help when warranted. [source: Kassam-Adams et al. 2011; Kassam-Adams ISRII 2009]
Start from the family's own top concern. This is the patient-centred posttraumatic-concerns approach of Zatzick et al. In practice, open every contact by asking what worries the child and the parent most. [source: Kassam-Adams et al. 2011; TSOS6 protocol]
Integrate with medical care. Physical recovery, pain and medical follow-up are part of the intervention. In practice, answer medical questions, track appointments and liaise with the medical team. [source: Kassam-Adams et al. 2011; NCTSN toolkit]
Prevention levels. The model follows the NIMH universal, targeted and indicated levels. In practice, everyone gets trauma-informed care, risk screening selects families for contact, and symptoms drive treatment. [source: Kassam-Adams et al. 2011]
Non-specialists deliver, specialists back them up. In practice, nurses and social workers run the low steps under psychologist supervision, with clear routes to psychology and psychiatry. [source: Kassam-Adams et al. 2011; TSOS6 protocol]
Information and choice for the child. In practice, explain what is happening, offer age-appropriate choices, and correct misconceptions. [source: NCTSN toolkit]
Use the family's own coping resources first. In practice, mobilise relatives, friends, school, clergy and hospital supports before adding professional services. [source: NCTSN toolkit; After the Injury]
Shared decision-making and a non-demanding style (adult model). In practice, elicit preferences (CBT, medication or both) and use a motivational-interviewing style. [source: TSOS6 protocol]
Graded tasks to build self-efficacy (adult model). In practice, set homework only when the person is ready, and increase difficulty gradually. [source: TSOS6 protocol]
No routine early trauma processing for everyone. In practice, do not run single-session debriefing or detailed recounting with all screen-positive children; offer memory-focused work only at step (e). [synthesis]

4. Intervention inventory

Interventions 1–14 make up the paediatric SPC model, its step-up options and its watchful-waiting supports. Interventions 15–19 are the adult stepped collaborative care components that SPC adapted; use them with injured adults or when adapting SPC to adults. Example language is my own illustrative wording throughout.

1. D-E-F bedside support (Step 0, universal)

Purpose / when: Reduce peri-trauma distress and spot families at risk. Used by every clinician in the emergency department, on the ward and at discharge, before any screening. [source: NCTSN toolkit]
Steps: (1) Distress: tell the child simply what is happening and what will happen next; offer age-appropriate choices; ask what they think happened and correct misunderstandings; ask about fears and worries; give realistic hope and reassurance. Manage pain actively, combining medication with relaxation or distraction during painful procedures. (2) Emotional support: encourage the parent to stay with the child and to talk about worries; show the parent concrete ways to comfort the child; restore normal activities where possible. (3) Family: gauge parental distress, coping resources and other stressors; encourage use of family, hospital and community supports; screen; involve psychosocial staff for higher-risk families; refer when indicated. At discharge, anticipate difficulties at home and problem-solve them in advance. [source: NCTSN toolkit]
Example language (illustrative): "The doctors are going to look at your leg with a special camera. It doesn't hurt. Do you want your mum to hold your hand or sit where you can see her?" / "Sometimes kids think an accident was their fault. What have you been thinking about what happened?"
Watch for: misconceptions (self-blame, believing someone died), panic during procedures, a parent too distressed to comfort the child, and family stressors that could block follow-up. A sign it is working is a calmer child who asks questions and seeks out the parent. [synthesis]

2. Early risk screening

Purpose / when: Identify the minority of children at higher risk who need active follow-up. Done during admission, within 2 weeks of injury. [source: Kassam-Adams et al. 2011]
Steps: (1) Check eligibility: age 8–17, unintentional injury, medically able to be interviewed, no moderate to severe head injury, child and parent able to complete the measures. (2) Give the Child PTSD Symptom Scale (17 DSM-IV symptom items; positive at 15 or more), the CES-D for depressive symptoms (positive at 24 or more in youth) and the STEPP. (3) Score immediately. One positive measure makes the child screen-positive, and the family is offered Session 1. [source: Kassam-Adams et al. 2011] The STEPP (Winston, Kassam-Adams and colleagues, CHOP, 2003) is a brief yes/no risk screen. It combines parent-reported items (e.g. witnessing the event, helplessness, the child's pre-existing behaviour or attention problems), child-reported items (e.g. others hurt, separation from parents, fear of dying) and medical-record items (e.g. suspected fracture, raised triage heart rate, age, sex), with separate child and parent cut-offs. It was developed with children injured in road traffic incidents. Injury severity on its own did not predict PTSD. [source: Relias/Clinician summary of STEPP; Kassam-Adams et al. 2011] The item count and cut-offs differ between sources: the 2011 trial reports 8 items with a cut-off of 4, while the trade summary gives 12 items with separate parent and child cut-offs. Use the published validation paper (Winston et al. 2003; journal not verified, see Sources) for scoring, not the trade summary. [uncertain]
Example language (illustrative): "We ask every family on this ward some questions about how the injury has affected everyone, because some kids have worries or bad dreams afterwards and we can help early. It takes about ten minutes."
Watch for: pain, sedation or fatigue distorting answers, so re-administer later if needed. Parent and child may answer differently. Screening is a risk estimate, not a diagnosis, so do not tell families the child "has PTSD". [synthesis]

3. Eliciting the top concern

Purpose / when: Engage the family by starting with what matters to them. This is the patient-centred posttraumatic-concerns approach (Zatzick et al. 2001). It opens Session 1 and every later contact. [source: Kassam-Adams et al. 2011; TSOS6 protocol]
Steps: (1) Ask the child and the parent separately, or in turn, what their biggest worry is right now. (2) Write each concern down in their own words. (3) Agree on what you can do about each one today (information, a contact, a referral). (4) Revisit the concerns at follow-up. [source for elicitation; steps 2–4 are synthesis]
Example language (illustrative): "Of everything that's happened since the accident, what's worrying you most right now?" / "For you as a parent, what's the thing keeping you up at night?"
Watch for: concerns that are practical or medical (missed work, cost, scarring, walking again) rather than emotional. Treat these as legitimate entry points. It is working when the family raises concerns spontaneously at the next contact. [synthesis]

4. Semistructured three-domain assessment (Session 1)

Purpose / when: Map current distress, supports and medical needs to set the level of care. Done in hospital, about 3 days after injury. [source: Kassam-Adams et al. 2011]
Steps: Cover (a) current distress: pain, fears, worries, and a review of the PTSD and depression symptoms endorsed at screening; (b) support systems: what helps and what gets in the way, including the parent's own distress and other family stressors; (c) questions about medical treatment. Then apply the decision rules (see Framework). [source: Kassam-Adams et al. 2011]
Example language (illustrative): "On the questionnaire you said you keep seeing the car in your head. How often has that happened today?" / "Who's been around to help you since this happened? Is anything making it harder for the family right now?" / "What questions do you have for the doctors that haven't been answered yet?"
Watch for: parental distress that may limit support for the child, pre-existing mental-health treatment, safety concerns or signs of non-accidental injury (which take you outside the protocol, see section 5), and suicidal thoughts. [synthesis]

5. Psychoeducation and the family binder

Purpose / when: Normalise reactions, teach warning signs and organise medical follow-up. Given in Session 1. [source: Kassam-Adams et al. 2011]
Steps: Hand over and walk through a binder containing tip sheets; a parent workbook (Helping You Help Your Child: Tools for Parents); a child workbook (Coping with Injury: Tools for Kids); information on medical care after injury; and a space to track follow-up appointments and questions for the doctor. Point out the warning signs and the follow-up date. [source: Kassam-Adams et al. 2011] The workbooks' content is [uncertain]. The publicly available After the Injury materials cover the same ground (see 6 and 7).
Example language (illustrative): "Feeling jumpy or upset in the first days is really common and usually settles. This page tells you what's normal and what would mean calling us sooner."
Watch for: literacy and language needs, and a parent too overwhelmed to take information in. Repeat the key points at Session 2. [synthesis]

6. Coaching parents to support the child's coping

Purpose / when: Strengthen the main protective factor, parental emotional support. From Session 1 onwards, for all screen-positive families. [source: After the Injury: Helping My Child Cope; Kassam-Adams ISRII 2009]
Steps: Coach the parent to: (1) tell the child they are safe and offer extra physical comfort, teenagers included; (2) let the child talk about feelings when they want to, say that feeling scared is normal, and ask open questions about worries or confusion; (3) offer drawing or story-telling (younger children) or writing (teenagers) if the child does not want to talk; (4) keep regular meals and bedtimes, with calming bedtime routines; (5) help the child keep up with school and get back to friends and activities as the injury allows; (6) spend more time doing shared family activities; (7) expect family members, including siblings who were not injured, to react differently. [source: After the Injury: Helping My Child Cope] The website pilot also targeted encouraging safe exposure to reminders, meaning gently not letting the child avoid safe situations. [source: Kassam-Adams ISRII 2009]
Example language (illustrative): "You don't need to make her talk about it. Let her know the door's open. 'If you ever want to talk or draw about the accident, I'm here.'" / "If he won't get in the car, start with short, safe trips with you, rather than avoiding cars altogether."
Watch for: parents forcing detailed retelling, overprotectiveness that blocks a return to activities, and parents' own avoidance. It is working when routines return, the child is back at school, and parent and child can talk about the event without escalating distress. [synthesis]

7. Parent self-care and parent-distress check

Purpose / when: Parent distress lowers the parent's capacity to help and is itself a risk. Address it in Session 1 and at follow-up. [source: After the Injury: Helping Myself Cope; Kassam-Adams et al. 2011]
Steps: (1) Normalise parent reactions: worry, stress, overprotectiveness and difficulty talking about the event. (2) Encourage sleep, regular eating, talking to supportive people, and asking for specific practical help (meals, childcare). (3) Encourage a return to routines and enjoyable family activities, and watch for unhelpful coping. (4) Give the signs that the parent needs help in their own right: feelings that stop them resuming usual activities, inability to talk with the child about the event, getting worse, or reactions lasting more than a month. Refer through their own doctor or a counsellor. [source: After the Injury: Helping Myself Cope]
Example language (illustrative): "Looking after yourself is part of looking after him. Who could bring a meal or take your other kids for an afternoon this week?"
Watch for: parent PTSD or depression symptoms, alcohol use, and guilt (especially if the parent was driving). Refer the parent separately rather than treating the parent inside the child's case. [synthesis]

8. Follow-up monitoring contact (Session 2, watchful waiting)

Purpose / when: Re-check trajectory after discharge. About 2 weeks after discharge, usually by phone. [source: Kassam-Adams et al. 2011]
Steps: (1) Review progress and any concerns about distress or symptoms. (2) Review support systems. (3) Review medical follow-up (appointments kept, pain, questions). (4) Apply the decision rules, then arrange further contact or services, or close with a plan for reassessment. [source: Kassam-Adams et al. 2011] Re-administering the screening measures at this point and again at about 6 weeks is my recommendation, in line with the authors' advice to make about 6 weeks the decision point. [synthesis]
Example language (illustrative): "Last time you mentioned nightmares. Have they been about the same, better or worse this past week?" / "Is he back at school? How's that going?"
Watch for: symptoms not improving or getting worse, new avoidance (school, cars, the hospital), and a family that is hard to reach. Repeated non-contact is itself a risk signal (see section 5). [synthesis]

9. Step-up (a): additional family contact

Purpose / when: Extra support or monitoring when needs are moderate or follow-up was incomplete. [source: Kassam-Adams et al. 2011]
Steps: Schedule one or more additional calls or visits focused on the unresolved concern; link the family to community resources for practical stressors. Contact can be combined with medical visits, phone or email, as the authors recommend. [source: Kassam-Adams et al. 2011; linkage detail from TSOS6 protocol]
Example language (illustrative): "I'd like to check in again in two weeks, after his clinic appointment. Would a call or a text be easier for you?"
Watch for: contact that keeps going without a goal. Set a reason and an end point for each extra contact. [synthesis]

10. Step-up (b): coordination with medical providers

Purpose / when: Support adherence to medical follow-up, solve medical problems that drive distress (such as pain), and make the medical team aware of the child's emotional recovery. [source: Kassam-Adams et al. 2011]
Steps: With parental consent, contact the surgeon, rehabilitation team or primary care provider; pass on relevant symptoms and family concerns; help arrange missed appointments; ask the provider to recheck emotional recovery at follow-up visits. [source: Kassam-Adams et al. 2011; NCTSN toolkit for outpatient monitoring] The After the Injury site includes a tool that lets parents rate the child's reactions and make a report for the doctor. [source: After the Injury, Find Ways to Help]
Example language (illustrative): "Would it be OK if I let Dr X know that Sam is still having trouble sleeping, so she can ask about it at the next appointment?"
Watch for: confidentiality boundaries with adolescents. Agree beforehand what will be shared. [synthesis]

11. Step-up (c): brief parent–child intervention

Purpose / when: Build a shared parent–child perception of the child's needs and help parents support adaptive coping. Used when parent and child see the child's distress differently, or when the parent needs more than written guidance. [source: Kassam-Adams et al. 2011]
Steps: The 2011 paper names this option but does not publish its structure. It cites Berkowitz et al.'s four-session parent–child model, the Child and Family Traumatic Stress Intervention (CFTSI). [uncertain] Whether SPC used CFTSI as such is not stated. CFTSI, as its developers' programme listing describes it, runs over 4–6 weeks for ages 7–18, soon after the event (within 30 days in its trial): (1) a caregiver-alone meeting (psychoeducation, assessment of caregiver and child symptoms, case-management issues); (2A) a child-alone meeting (psychoeducation, symptom assessment); (2B) a family meeting, which is the key session: compare the child's and caregiver's symptom reports, pick specific reactions to target, and introduce coping skills; (3) a family session to review communication and progress, reassess and practise skills; (4) a family session to reassess and decide on further treatment or case-management needs. Between sessions, the family practises the skill and records it in a family log. Delivery is by master's-level therapists after 2-day developer training. [source: CEBC CFTSI page; CrimeSolutions CFTSI profile]
Example language (illustrative): "Jess said the worst thing is not being able to sleep; you'd guessed it was her leg. Let's put those side by side and work out what would help her at bedtime."
Watch for: parents minimising or over-reading symptoms, and children protecting the parent by under-reporting. A sign it is working is closer agreement between parent and child reports, with the parent using the coping skill with the child between sessions. [synthesis]

12. Step-up (d): specialist evaluation

Purpose / when: Formal psychological or psychiatric assessment when symptoms are significant, persistent or complex (including depression, suicidality, prior psychiatric history, or questions about medication). [source: Kassam-Adams et al. 2011]
Steps: Refer to the team psychologist for diagnostic assessment (for example a structured PTSD interview such as the CAPS-CA, as in the Kenardy et al. protocol) and to child psychiatry for medication assessment. Report back to the family and medical team and choose the next step. [source: Kassam-Adams et al. 2011; Kenardy et al. 2010]
Example language (illustrative): "The bad dreams and staying away from school have hung around longer than we'd expect. I'd like you to meet Dr Y, who specialises in helping kids after accidents, to work out the best help."
Watch for: referral drop-out. Make a warm hand-off, with a named person and a date. [synthesis]

13. Step-up (e): trauma-focused CBT for severe or persistent PTSD

Purpose / when: Treat severe or persistent PTSD symptoms that have not resolved with the lower steps. [source: Kassam-Adams et al. 2011]
Steps: SPC does not specify a protocol. [uncertain] One published early-intervention example for injured children is Kenardy, Cobham et al.'s programme, delivered weekly in sessions of about 1.5 hours with a psychologist. The child programme (6 sessions, Me and the accident) is strengths-based and uses drawing and writing. It covers psychoeducation on thoughts, avoidance and body reactions; the child's account of the accident and current sense of danger; identifying "hot spot" thoughts or images; challenging hot spots and managing intrusive thoughts; and future planning and relapse prevention. The optional parent programme (4 sessions, given first) covers psychoeducation, danger perceptions and how parents may communicate threat, changes in parenting after trauma, and skills for parenting a child with PTSD. That trial entered children with full or partial PTSD at 4–6 weeks on the CAPS-CA. It excluded moderate to severe head injury, developmental delay, severe depression or suicide risk, caregiver substance misuse or psychosis, child-protection involvement, and abuse-related injury. [source: Kenardy et al. 2010 protocol]
Readiness and safety: before memory-focused work, the child should be medically stable, with pain managed, living in a safe setting, and not acutely suicidal. Pace the trauma narrative and hot-spot work so distress stays tolerable. Close every session with grounding and a return to the present. Stop and stabilise if the child dissociates (see section 5). [synthesis, consistent with the exclusions above]
Example language (illustrative): "We're going to make your story of the accident, with a good ending, the part where you got better. We'll go at your pace, and you can stop any time."
Watch for: worsening avoidance, dissociation, and sleep deterioration. A sign it is working is reduced distress at hot spots and a more realistic sense of current danger. [synthesis]

14. Web-based or video resource for watchful waiting

Purpose / when: Extend low-intensity support and prepare parents to judge the child's reactions, help, and seek help when warranted. The SPC authors propose web resources as part of watchful waiting. [source: Kassam-Adams et al. 2011; Kassam-Adams ISRII 2009]
Steps: Direct parents to CHOP's After the Injury site, which was tested as a 20-minute guided session or a 20-minute video (DVD for families without internet). Point them to the sections on self-care, when to get outside help, injury and pain care, working with the health care team, the 1-2-3 care plan, and the follow-up-visit tool that rates the child's reactions for the doctor. Ask them to bring the report to the next contact. [source: Kassam-Adams ISRII 2009; After the Injury, Find Ways to Help]
Example language (illustrative): "There's a short website made for parents after a child's injury. Could you spend 20 minutes on it this week and fill in the reactions checklist? We'll look at it together when I call."
Watch for: in the pilot, parents' confidence rose and their answers about avoidance and symptom duration became more accurate, but overall knowledge scores did not change significantly. Do not rely on the site alone for high-risk families. [source: Kassam-Adams ISRII 2009]

Interventions 15–19 are adult stepped collaborative care components (Zatzick, University of Washington), as specified in the TSOS6 protocol. SPC adapted this model. [source: TSOS6 protocol; Kassam-Adams et al. 2011]

15. Care management with concern elicitation and shared decision-making

Purpose / when: Engage injured adults and coordinate care from the bedside to 6 months after injury. Used with adults identified by an EHR risk screen (3 or more of 10 risk domains) and a PTSD Checklist score of 35 or more. [source: TSOS6 protocol]
Steps: (1) Meet the patient during the trauma-centre or ED stay. (2) Elicit and act on their posttraumatic concerns. (3) Elicit treatment preferences (CBT, medication, or both) and reach shared decisions with the patient, family and providers. (4) Schedule contacts over the following days and weeks. (5) Record each contact in the decision-support tool for supervision. (6) In the final contact, plan ongoing care and hand off to primary care. [source: TSOS6 protocol]
Example language (illustrative): "Some people want to talk through stress, some want to try medication, some want both, and some want neither for now. What fits you?"
Watch for: missing primary-care providers (about 40% have none at admission), unstable housing, and legal or financial stressors. [source: TSOS6 protocol]

16. Motivational interviewing elements

Purpose / when: Build engagement and target risky behaviours, especially alcohol and drug use. This is embedded in care management. [source: TSOS6 protocol]
Steps: Follow a graded sequence: elicit the person's views on change and their confidence; give personalised feedback (for example on screening results); clarify goals and an action plan. Keep a non-demanding style. Fidelity is coded with the MITI. [source: TSOS6 protocol]
Example language (illustrative): "On a scale of 0 to 10, how important is cutting back on drinking while you recover? What makes it a 5 and not a 2?"
Watch for: arguing for change (the "righting reflex"). Signs it is working are change talk and a concrete, self-chosen plan. [synthesis]

17. Brief CBT elements

Purpose / when: Address acute PTSD and depressive symptoms in the early step. [source: TSOS6 protocol]
Steps: For PTSD symptoms: psychoeducation, problem-solving, breathing exercises, and behavioural-activation homework. For depression: psychoeducation, problem-solving, activity scheduling, attention to experience, and behavioural activation. Give homework only when the patient shows adequate readiness, and grade task difficulty upward to build self-efficacy. [source: TSOS6 protocol]
Example language (illustrative): "Let's pick one small thing you used to enjoy that your injury still allows, maybe ten minutes outside, and plan when you'll do it this week."
Watch for: pain and physical limits constraining activities, so adjust tasks with the medical team. A sign it is working is completed activities and improving mood or PTSD Checklist scores. [synthesis]

18. Medication consultation pathway

Purpose / when: Offer pharmacotherapy to patients who choose it, as the sustained step for chronic symptoms. [source: TSOS6 protocol]
Steps: Take an accurate medication history and reconcile discrepancies; discuss choices in team staffing with the supervising psychiatrist; recommend guideline-concordant SSRI treatment through the prescriber (the team usually does not prescribe, except temporarily during transitions); hand off medication management to primary care at the end. [source: TSOS6 protocol] Dosing is outside the scope of this guide.
Example language (illustrative): "If you'd like to consider medication, I'll talk it over with our psychiatrist and your doctor so everyone's working from the same list."
Watch for: interactions with analgesics, and discrepancies between hospital and community medication lists. [synthesis]

19. Trauma-centre to primary-care linkage

Purpose / when: Bridge the gap after discharge, the point where many patients are lost to follow-up. [source: TSOS6 protocol]
Steps: Reconcile medications between hospital and primary care; communicate the discharge plan; arrange primary-care follow-up, or find a provider if the patient has none; involve the family; link to community resources. [source: TSOS6 protocol]
Example language (illustrative): "You told me you don't have a regular doctor. Let's book you one before you leave, and I'll send them a summary."
Watch for: no-shows. Confirm that the appointment happened. [synthesis]

5. Handling problems

The SPC sources document only the delivery problems marked with a [source] tag. All other responses are my own synthesis.

Discharged before first contact. In the pilot, 5 of 46 intervention cases were missed this way, and short stays limited recruitment. Response: screen and deliver Session 1 as early in the admission as the child's medical state allows; flag screen-positive children to the discharge nurse; if they are missed, give Session 1 by phone within the week. [source: Kassam-Adams et al. 2011 for the problem; response is synthesis]
Family unreachable for follow-up. Session 2 was completed with only 54% despite repeated attempts. Response: the authors recommend running SPC as routine care through nurses and social workers rather than as research, and combining follow-up with medical visits or doing it by email or phone. [source: Kassam-Adams et al. 2011] Add: get two phone numbers and preferred contact times in Session 1; book the follow-up for the same day as a clinic visit; send the parent the reactions checklist; treat repeated non-contact in a child who screened high-risk as a reason to contact the medical team, not a reason to close the case. [synthesis]
Low-intensity steps not enough for high-risk children. Response: do not wait longer than about 6 weeks. Reassess then, and step up directly to the parent–child intervention or trauma-focused treatment if symptoms persist. [source: Kassam-Adams et al. 2011] For children with very high early symptoms, severe depression or prior psychiatric history, consider going straight to step (d) rather than starting at Step 1. [synthesis]
Child already in mental-health treatment. Response: coordinate with the existing provider instead of running a parallel stepped pathway; share the injury-related screening results with consent. [synthesis; the pilot noted that imbalance in recent treatment complicated outcomes, source: Kassam-Adams et al. 2011]
Parent and child disagree about distress. Response: use step (c). Collect separate reports, then compare them in a joint meeting, as CFTSI does in Session 2B. [source: CEBC CFTSI page] Expect children to under-report to protect a distressed parent, and parents to under- or over-read symptoms. [synthesis]
Child will not talk about the injury. Response: do not push for a narrative at the prevention steps. Offer drawing, writing or play; focus on routines and safe re-engagement with activities; reassess. [source for drawing and writing: After the Injury: Helping My Child Cope; the rest is synthesis] Persistent, impairing avoidance at 4–6 weeks means stepping up to (d) or (e). [synthesis]
Parent highly distressed, guilty, or was involved in the event (e.g. the driver). Response: normalise the reactions, give the parent self-care guidance, and refer the parent to their own doctor or a therapist if their reactions interfere with daily life or parenting, are getting worse, or last more than a month. [source: After the Injury: Helping Myself Cope] Keep the child's sessions focused on the child, and address guilt in the parent's own care. [synthesis]
Overwhelm or dissociation during a contact or in step (e). Response: stop the trauma content; orient the person to the present (name the room, the date, the people present); use slow breathing, which is an element taught in the adult model; check pain and medical needs; end with a plan and a named contact. Resume memory work only when the client can stay present. [synthesis; breathing source: TSOS6 protocol]
Suicidal ideation or self-harm. Response: any positive item triggers an immediate same-day risk assessment by a qualified clinician, notification of the responsible medical team, safety planning with the family, and lethal-means counselling (safe storage or removal of medicines and other hazards at home). [synthesis] In the adult model, a PHQ-9 suicide-item score of 1 or more triggers nurse notification. [source: TSOS6 protocol] Severe depression or suicide risk was an exclusion for early CBT trials, so stabilise first. [source: Kenardy et al. 2010]
Non-accidental injury, abuse or domestic violence suspected. SPC trials enrolled only unintentional injuries, and the Kenardy trial excluded abuse-related injury. [source: Kassam-Adams et al. 2011; Kenardy et al. 2010] Response: follow local safeguarding and mandatory-reporting duties, and route the child to child-protection services and abuse-specific trauma services rather than the standard SPC pathway. [synthesis]
Head injury, posttraumatic amnesia or cognitive difficulties. Response: these were exclusions in both trials, so defer self-report screening until the child has cleared posttraumatic amnesia, use parent report and neuropsychology input, and adapt materials. [source for exclusions: Kassam-Adams et al. 2011; Kenardy et al. 2010; response is synthesis]
Depression rising during the prevention phase. In the pilot, depression and quality-of-life results went in the unexpected direction for the intervention group. Response: monitor depression as well as PTSD at each contact, and step up to (d) for depressive symptoms even when PTSD symptoms are falling. [source: Kassam-Adams et al. 2011 for the finding; response is synthesis]
Non-adherence to homework or medical follow-up. Response: in the adult model, homework is given only when the patient is ready and is graded upward. [source: TSOS6 protocol] Use step (b) to tackle barriers to medical follow-up (transport, cost, no primary-care provider). Use MI to explore ambivalence rather than repeating instructions. [synthesis]
Engagement refused or stigma ("we're fine"). Response: frame contact around the family's own top concern and practical medical help rather than mental health; leave written warning signs and a contact route; arrange one low-burden check-in call. [synthesis, drawing on the top-concern approach in Kassam-Adams et al. 2011]
Rupture (family feels intruded on, or that their concern was dismissed). Response: acknowledge it directly, return to their stated concern, offer choice about the timing and channel of contact, and reduce frequency instead of ending contact abruptly. [synthesis]
Over-pathologising normal reactions. Response: screening is a risk estimate, so use non-diagnostic language and stress the expected natural recovery. [source for natural recovery: After the Injury: Helping My Child Cope; the rest is synthesis]
Pain driving distress. Response: assess and treat pain, combining medication with behavioural techniques such as relaxation or distraction, and coordinate with the medical team through step (b). [source: NCTSN toolkit]
Supervision gaps for non-specialist interventionists. Response: the published models use doctoral-level supervision (SPC) or weekly individual supervision plus team calls and decision-support logging (adult model). Build in a fixed weekly case review of every screen-positive case. [source: Kassam-Adams et al. 2011; TSOS6 protocol; the weekly SPC frequency is synthesis]

Sources

Sources:

Further reading (not drawn on; details as reported in the sources):

Kassam-Adams N, García-España JF, Marsac ML, Kohser KL, Baxt C, Nance M, Winston F (2011). A pilot randomized controlled trial assessing secondary prevention of traumatic stress integrated into pediatric trauma care. Journal of Traumatic Stress, 24(3), 252–259.
Winston FK, Kassam-Adams N, Garcia-España F, Ittenbach R, Cnaan A (2003). Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA, 290(5). [uncertain: journal not verified; the search results link the STEPP to PubMed 12902368]
Zatzick D, et al. (2004). A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Archives of General Psychiatry. [uncertain]
Zatzick D, et al. (2001). Posttraumatic concerns approach (patient-centred), cited in Kassam-Adams et al. 2011. [uncertain]
Berkowitz SJ, Stover CS, Marans SR (2011). The Child and Family Traumatic Stress Intervention: secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry. [uncertain]

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